Transcription:
Substance Use Disorder and COVID-19

Melanie: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and joining me today is Dr. Daniela Rakocevic. She's a physician at Northwestern Medicine, an expert in addiction and an Assistant Professor of Psychiatry and Behavioral Sciences.

She's joining us today to discuss substance use disorder and the COVID-19 pandemic. Dr. Rakocevic, I'm so glad to have you join us today. First of all, tell us a little bit about the work you're doing at Northwestern Medicine as it relates to addiction.

Dr Daniela Rakocevic: Well, thank you, Melanie, so much. It's my pleasure. I actually joined Northwestern Department of Psychiatry last summer, so in the middle of the pandemic. And my primary focus this time apart from clinical work is actually development of clinical services geared towards our patients with substance use disorders and co-occurring mental health conditions that we sometimes also call dual diagnosis.

And, you know, there's certainly a gap in between what's generally needed and what is available for our patients with addiction. And I think this has been even more pronounced in the last 12 months of the pandemic. So I think one major part of what we're doing right now is development of our outpatient addiction clinic.

But also I think in a broader sense, looking more into how can we as addiction experts increase collaboration with our colleagues from other specialties, for example, primary care and therefore, improve disease recognition and improve access to addiction services across the board.

And I will say also I love teaching. I love working with medical students, with residents. I additionally serve as Associate Program Director for our Addiction Psychiatry Fellowship. And my not so hidden agenda is always to spark interest in my learners and to interest them in the field of addiction psychiatry.

Melanie: Such an interesting field you're in. And right now, even more so, data has shown us that there's an increase in substance abuse as a way of coping with the stress of this pandemic. Tell us about the intersection of substance use disorder and COVID-19, and tell us a little bit about what you've seen.

Dr Daniela Rakocevic: Yes, unfortunately, as physicians, what we have seen, what we are witnessing on a day-to-day basis is that in the past year, I think the new norm for a lot of people became isolation, loneliness, uncertainty, health and financial distress. I think also grief and despair. And I think at this point, 12 months into the pandemic, we have some very concerning data regarding substance use increase.

According to the CDC, so Centers for Disease Control and Prevention, in June 2020, we had 13% of Americans that reported starting or increasing their substance use to cope with the stress of pandemic. And there is a spike in overdoses since the onset of pandemic. There is a particular monitoring reporting system called ODMAP, that at the very beginning of the pandemic early on told us that there was an 18% increase compared to March 2019.

And this trend actually just continued in 2020. So in December 2020, we had a situation where more than 40 US states have seen increases in opiod-related mortality and other adverse effects. So in a sense, I would say pandemic with COVID-19 was superimposed on the already existing epidemic of substance use disorders, worsened it, and then that compounded profoundly negative effects that we're seeing right now.

Melanie: Well, I'm sure that we are. So what can physicians and healthcare providers listening to this podcast do to help their patients who are struggling with substance use disorders during these times? What would you like them to know?

Dr Daniela Rakocevic: I would definitely like to highlight three things in regards to helping our patients with addiction and I think they can be universally implemented, but I think they're especially valuable now in the context of pandemic. I think, first and foremost, it is important to identify the problem if there is one. I cannot emphasize enough the importance of screening. So basically asking our patients questions about substance use. Simply put, we cannot start treating addiction if we don't know that one exists.

And secondly, I think meeting patients where they're at with their substance use always goes a long way. I mean, some of our patients are ready for recovery and abstinence and some are not. And their health goals might be different, but I personally prefer the flexible approach where we as physicians can actually practice motivational enhancement, we can focus on this progress-not-perfection attitude and motivate our patients to make healthier choices in their lives. And certainly some of our patients will need more support and more structure to be able to decrease or even fully stop their substance use. Some of them may require referrals to addiction experts, to addiction counseling or various forms of treatment.

And I think third point finally, I think it's very important to use every single opportunity, especially with our patients with addiction, to educate and to reiterate the importance of social distancing, hand-washing, wearing masks and ultimately and absolutely getting vaccinated from COVID-19. And I can say that here at Northwestern Medicine, we are doing a very good job. We are leading by example due to various efforts to mitigate risk of spreading the virus, educating our patients, providing continuity of care during the pandemic via telehealth services.

Melanie: Expand just a little bit on that for us, telehealth. How has that been very useful, especially during this time with people that are struggling with addiction? You've gotten to maybe even see the insides of their homes or it might've helped you in ways you didn't realize. Tell us some things that might have surprised you about using telehealth for substance use disorders.

Dr Daniela Rakocevic: Yeah, I think that's an excellent question. I will say that I had the opportunity to publish a review paper with colleagues from Mayo just recently on the use of telehealth during the COVID-19 pandemic, a nice paper that overviews like safe and effective telehealth implementation strategies and some advantages and disadvantages of using telehealth, or not disadvantage, but more challenges in the treatment of our patients with addiction.

But basically, what happened is starting a year ago, due to infection, the inability to do in-person treatment widened the already existing gaps in the access to addiction treatment. And, fortunately, federal and state agencies have rapidly responded to the crisis by loosening restrictions on telehealth to provide us much needed medical care.

And additionally, I will say, as an addiction psychiatrist, a life-saving intervention was a change in the treatment of opioid use disorder. For example, ability for us to prescribe buprenorphine, a very important medication for treatment of opioid disorder via telehealth without in-person visit, or for example, the ability of our patients in methadone clinics to have more take-home doses and therefore decrease their exposure to coronavirus.

So as someone who has been practicing a lot of telehealth, I think, since the onset of pandemic, I can really say that it lowered the barrier to care. Patients really, really love it. It decreases the cost of care because they don't have to commute. I think that we're all hoping that some of the telehealth changes that I started last year are here to stay.

Melanie: Isn't that an interesting aspect of this pandemic, what we're seeing in these advances in telehealth. And tell us a little bit about patients who have had or who have COVID-19 and addiction or substance use disorders. Are they at an increased risk for adverse outcomes?

Dr Daniela Rakocevic: Melanie, I think that this is the key question and actually the one that we can now answer very confidently thanks to the amazing work of Dr. Nora Volkow, who is Director of NIDA, National Institute on Drug Abuse, actually most prominent addiction expert in our country.

So briefly, Dr. Volkow and her research team did a retrospective case-control study on a very robust sample. So they reviewed over 73 million health records covering 360 hospitals and all 50 states represented. And I think it was very clear from their analysis that people with substance use disorders are indeed at a higher risk of contracting COVID-19 and also suffering worse consequences from the infection. And this was very especially true for African-Americans.

So I think what this particular research showed is that the risk of COVID-19 was highest among those who were actually diagnosed with substance use disorder within the past year, so within last 12 months. So what would that basically mean? That would mean if you had a new diagnosis of opioid use disorder in the past 12 months, you were a little bit over 10 times more likely to be diagnosed with COVID-19 than a person without it. For tobacco use disorder, that's more than eight times more likely. For alcohol, a little bit less than eight times. For cocaine, for cocaine use disorder, 6.5 times. And finally, the final substance that was looked into was cannabis. So for cannabis use disorder five times.

So in this, I think, particular sample, if we look at patients that had a lifetime diagnosis of addiction, of substance use disorders, they were at the baseline one and a half times more likely to get COVID. So this particular subset of patient actually had worse outcomes. They had more hospitalizations and more deaths. And I think this was the particular group of patients, the particular subset, where we have seen that discrepancy between African-American and Caucasian patients with African-American patients having worse outcomes.

And I think, the major question is why is this combination of COVID-19 and addiction is so problematic. What happens? And the reasons are probably very complex, as Dr. Volkow was explaining, that many kinds of chronic substance use actually harm our body, weaken our body in ways that make people who use substances more vulnerable to infection. We know that, for example, opiates can compromise respiration. They can weaken the immune system.

Speaking of tobacco and cannabis, both smoking and vaping, respiratory health in a person could be suboptimal at baseline and then COVID happens. We are seeing increase in the use of stimulants. So stimulants such as cocaine or methamphetamine affect cardiovascular health. So I think addiction with COVID-19 infection really creates a particularly deleterious combination.

Melanie: Well, it certainly doesn't. And as we wrap up, what an interesting informative episode this is. Share any other information that you think is important for other providers to know about treating patients at this time with addiction and any treatment options that you think that have been grossly underutilized, how they can get more people into these types of programs, to look into these types of programs. Any closing thoughts you'd like to share?

Dr Daniela Rakocevic: I think instead of that, I will give you something that was a parting message that was conveyed by Dr. Anthony Fauci during his recent participation in the Addiction Policy Forum when he was talking to people about COVID-19 and treatment of addiction in this difficult time. And he said in his signature style, messages that was very meaningful for me, and he said, "This is going to end. There is a light at the end of the tunnel." And I think that this is a message of hope that's equally important for our physicians and our patients as well.

Melanie: Beautifully said. And I absolutely agree with you. Thank you so much, doctor, for joining us today. And to refer your patient or for more information, you can visit our website at nm.org to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. Please remember to download, subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.